| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | The "Rights" form, signed by Individual #1 on 5/26/15, did not state the full rights per regulation 33(h) regarding telephone access.
Per 6400.33(h) "An individual has the right to reasonable access to a telephone and the opportunity to receive and make private calls, with assistance when necessary." | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | The Quality Compliance Specialist revised the ¿Rights¿ form to include telephone access (attached). The Program Specialist reviewed the revised ¿Rights¿ with Individual #1 and obtained a signed copy on 11/2/15. The Records Technician sent the revised rights form to their family/guardian (attached). The Records Technician will send all individuals and their guardians a copy of the revised rights form at the annual update cycle date in January 2016 |
11/02/2015
| Implemented |
| 6400.141(c)(7) | Individual #1's most recent breast examination was completed on 6-10-15. Individual #1 was admitted to respite care in the home on 5-1-15. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Due to Individual¿s emergency respite, her exam was late based on scheduling but was completed on 6/10/15. The process and policy was reviewed by VP of Nursing, Chief Operational Officer, and Director of Residential Services/Admission. There are no changes being made to policy and procedure. Moving forward, all exams will be completed within the 30 days of admission for emergency respite placements. The Director of Residential Services/Admissions will monitor for ongoing compliance. [Medical appointments for a physical examination and dental care shall be made by the Director of Residential Services/Admissions as soon after an individual is receiving emergency placement services to ensure completion within 31 days. (AS 12/2/15)] |
11/07/2015
| Implemented |
| 6400.181(d) | The program specialist did not sign and date the assessment for Individual #1 completed on 7-17-15. | The program specialist shall sign and date the assessment. | Program Specialist signed the assessment for individual #1 on 10/30/15. Director of Program and Residential Services added a signature and date line to the assessment form on 10/6/2015. Retraining was provided by the Program Director to the Program Specialists at their monthly meeting on 10/14/2015.
The Program Director will review all completed Assessments to ensure they are signed and dated by the Program Specialist for ongoing compliance.
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10/30/2015
| Implemented |